Laura Kirmayer, PhD, MSW Director of Brave Buddies
Transcript of Laura Kirmayer, PhD, MSW Director of Brave Buddies
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Climbing the Ladder: Practicing Brave Talking Laura Kirmayer, PhD, MSW Director of Brave Buddies
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Child Mind Institute Founded in 2009 The only independent nonprofit organization exclusively dedicated to transforming mental health care for children everywhere.
To help children reach their full potential we must:
• Develop more effective treatments for childhood psychiatric and learning disorders.
• Empower children, families and teachers with the scientifically sound information they need.
• Build the science of healthy brain development.
The Child Mind Institute does not accept funding from the pharmaceutical industry.
“The Child Mind Institute dares to imagine a world where no child suffers from mental illness.”
-Brooke Garber Neidich, Chair, Child Mind Institute
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Upcoming Events
Behavioral and Emotional Skills Training A one-day training for caregivers and parents to teach practical techniques for effective behavior management. Friday, February 26, 2016 9:00 AM – 4:00PM
Coexisting Disorders in Children with SM: How to Differentiate Symptoms and Navigate Behaviors Presented by Laura Kirmayer, PhD, MSW, and Michelle Kaplan, LCSW Wednesday, March 16, 2016 6:15 PM – 7:30 PM A Team Approach: Collaboration and Coordination with Schools Presented by Janine Domingues, PhD Wednesday, April 13, 2016 6:15 PM – 7:30 PM
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Outline for Our Time Together
• Selective Mutism: 101 Abbreviated • Building Brave Muscles Abbreviated • Climbing the Ladder: Targeted
Practice • Take it on the Road: Daily Practice • Questions and Discussion
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SELECTIVE MUTISM: 101 ABBREVIATED
(Watch SM 101 from October 17th, 2015)
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What is Selective Mutism (SM)?
• The inability to verbalize in specific social situations when speaking is expected (e.g. school, extra-curricular activities, play dates) despite the ability to verbalize fluently in other situations (e.g. home)
• Causes Impairment • Duration for at least 1 month, not including
the 1st month of school
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Current Conceptualization of Selective Mutism
Nature and Nurture
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ANXIETY
Genetic Predisposition
ANXIETY
Nature
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Nurture
The Environment's Role in Shaping the Inhibited
Stance
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Our treatment is a behavioral approach that focuses on the *environment’s role in shaping
the inhibited stance.
*Environment: Anyone (parent, teacher, peer, stranger) prompting the child to engage verbally and/or behaviorally
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Child is Prompted to Engage Verbally
or Behaviorally
Child Experiences Distress &
Inhibits
Environment Observes Distress
Environment Has Empathic
Response
Every One Feels Relief
Negative Reinforcement
Environments Role in Shaping the
Inhibited Stance
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EFFECTIVE TREATMENT
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Treatment Goals • Develop the child’s capacity to
manage anxiety related to speaking so that the child is able to overcome its impact (Building Brave Muscles)
• Increase number of people, settings and activities in which the child speaks responsively and spontaneously(Climbing the Ladder)
• Diminish anxiety
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Treatment Approach • Behavioral Therapy (BT) or Combined BT &
Medication • Not Treatment As Usual (‘TAU’)
§ Intensive dose to build momentum § Targets generalization
• Team Approach § Parents, teachers, caregivers
• Simultaneous Treatment Trajectories § Caregivers Skills Training and Acquisition § Child’s Individual Trajectory § School Intervention Plan § Ongoing Assessment
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Crucial Components of Effective Treatment
• Psychoeducation • ‘Environments’ Distress
Tolerance • Consistent Daily Dose • Graduated and Systematic
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Psychoeducation • This includes the child, parents,
teachers and even friends and friends parents, store clerks and doormen!
• Treatment is transparent* and collaborative. We need everyone on board.
• Really important to debunk the myths that may interfere with how we approach the child and the anxiety
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Distress Tolerance
• Build the environments awareness of their own distress and their response to distress
• Natural instinct is to help a child in distress
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Daily Dose that Stays Graduated and Systematic
• Think about how you learn any new behavior… § Learning how to read § Learning a new language
• Time and repetition
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TREATMENT PLAN
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We Start By Creating A Talking Map
Create one as we run through the
next slides…
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Rigid Rules • Kids with SM divide
the world into those they talk with and those they don’t
• Boundaries are not fluid
• Multiple variables influence these boundaries : People, Places and Activities
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People, Places, and Activities
• Unique variations from child to child • Treatment needs to be
individualized to these variations § Same goal and same approach, but
different starting points and different sized steps
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The Contamination Effect
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REMINDER: Graduated and Systematic
Put the Map Aside and focus on
Skills Mastery
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BUILDING BRAVE MUSCLES
ABBREVIATED (Watch Building Brave Muscles Workshop
from November 18, 2015)
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Adaptation of Parent Child Interaction Therapy (PCIT) for Selective Mutism
• PCIT is an empirically supported treatment for young children with disruptive behavior disorders
• Adaptations have been developed for many populations outside of DBD
• Dr. Steven Kurtz developed the adaptation of PCIT for Selective Mutism
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SM Behavioral Skill Modules • Child Directed Interaction (CDI)
§ Reward/ Reinforcement • Verbalization Directed Interaction (VDI)
§ Exposure/ Approach Task § Effective sequences when prompting child to speak
• Fade-in § Passing the ‘talking baton’ § Generalization
• Targeted Exposures § Climbing the Ladder(s)
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NO QUESTIONS PLEASE!
Remove the expectation to speak
and build a comfort level
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Child Directed Interaction (CDI) PRIDE Skills
• Praise - Labeled Praise (LP) • Reflect (RF) • Imitate • Describe- Behavior Descriptions (BD) • Enthusiasm
****AVOID • Questions, commands, criticism, sarcasm
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AVOID MINDREADING!!!
Pull for the Narrative through Behavior Descriptions!
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ANY Verbalization in CDI…
REFLECT and LABELED PRAISE IT!
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Daily Skill Practice
• 5 minutes daily § 10 behavioral descriptions § 10 labeled praise § reflect ALL verbalizations (if any) § 0 questions § 0 commands to verbalize § **0 mindreading
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Gradually and Systematically
• Sensitize child to our presence with the CDI skill set
• Graduate the child to verbalize in our presence by systematically integrating the VDI skill set into CDI
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Verbalization Directed Interactions (VDI)
Providing the child with opportunities to build brave muscles
The PLANNED and INTENTIONAL use of prompts for verbalizations in a graduated and systematic approach
Providing opportunities for the child to practice approaching instead of avoiding or becoming inhibited
VDI always follows warm-up with CDI and is never used alone. It is a CDI/VDI dance!
(CDI and VDI are integrated together)
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Forced Choice or Open Ended
Question or Direct Command for Verbalization
Verbal Response No Response Nonverbal Response
Effective VDI Sequence
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Forced Choice or Open Ended Question /or
Direct Verbal Command or Prompt for Verbalization
Verbal Response
Reflection and Labeled Praise
No Response
Wait 5 seconds Reformat or Repeat
Question
Nonverbal Response
Behavior Describe and Neutral Prompt for Verrbal response
No response/ nonverbal
Wait 5 seconds and “Plan B”
Verbal Response
Reflection and Labeled Praise
Effective VDI Sequence
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Daily Skill Practice
• Pacing of CDI with VDI when NOT inhibited
• Pacing of Transition from CDI into CDI/VDI
• Integrate play into practice
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Games that Elicit Verbalizations (when in VDI!)
• Go Fish • Zingo • Hangman • Headbandz • Guess Who
• Surveys of Favorites
• Spot It • Tell Tale
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Daily Homework (so far…) • Attend to the cycle: awareness is crucial first
step • Monitor your use of questions or prompts to
verbalize • Practice CDI and CDI/VDI 5 minutes daily to
gain mastery and to acclimate § Needs to become fluid, like a second
language • Establish several games or activities that
your child enjoys and that promote the skills
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Climbing the Ladder: Targeted Practice
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How to Get Started • Practice the skills 5 minutes daily to gain
mastery § Needs to become fluid, like a second language
• Refer to the map we created and establish the first target
• Select planned and intentional situations to begin using the skills in a TARGETED PRACTICE
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Targeted Prac0ce • Exposure: An exposure is an Approach Task
that helps the child successfully encounter or experience the very thing that they have been avoiding
• Success- oriented
• Repetition-Consistency-Momentum
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Ini0al Targets • Remember the INITIAL goal is to increase the number
of people, places and activities that the child can successfully verbalize across
• Target ONE variable at a time until momentum builds
• Initial targets do NOT address: Volume, Voice characteristics, latency, number of word utterances, eye contact, body language….OR behaviors!*
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Example of A Targeted Prac0ce: The Fade In…
• No expectation to speak (no questions) • Speak to parent in our presence • Speak to us with parent in the room • Speak to us with parent no longer in the room
Once successfully faded in…repetition and building momentum before next target!
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Pause to discuss…
Accommodation Versus Enabling
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Accommodate versus Enable
• Graduated and systematic process with repetition/rehearsal for mastery
• Place temporary accommodations in place until mastery is achieved
• Once mastery has been acquired and accommodations are no longer necessary…avoid ENABLING!
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Examples of Accommoda0ng versus Enabling
• Child has never verbally participated in Morning Meeting, but behaviorally engages fully § Prompt child to participate non-verbally: “Come up to the
board and point to what month it is” “You pointed to January”
• Target ability to verbalize in morning meeting (Targeted Practice Plan) § Once child has successfully mastered verbalizing in
morning meeting a prompt for non-verbal participation is ENABLING
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Examples of Accommoda0ng versus Enabling
• Child has never verbally greeted others (hello), but will wave § Prompt child to wave § “Wave hello to Laura” : ACCOMMODATION
• Child has never asked to use the bathroom in
school § Provide child with option to flip over a card to signal
the need to use the bathroom : ACCOMODATION
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Back to Targeted Practice…
Keeping accommodation versus enabling in mind
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Targeted Practice Example
Counselor: We are going to have a treat today. We are going to get ice cream. Do you want chocolate, vanilla, or something else? Child: Chocolate. Counselor: Chocolate! Thanks for telling me. Do you want it in a cup or a cone? Child: A cone Counselor: Great job telling me you chocolate ice cream in a cone. So when we get to store the person will ask say, “What can I get you?” What would you say back to him? Child: Chocolate ice cream Counselor: Did you want it in a cup or cone? Child: A cone Counselor: Great job ordering your ice cream. Let’s try again!
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Pause to discuss…
DEGREES OF TRANSPARENCY
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Examples of Degrees of Transparency
• Playing Spot it with Child in the classroom as the teacher walks in and out
• Playing I spy around the hallways of the school • Playing Brave Bingo or Favorites • Planning a specific target with child…Show and Tell
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Back to Targeted Practice…
Keeping Degrees of Transparency in Mind
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Effec0ve Targeted Prac0ce
• Graduated and systematic § Keep your eye on the ball
• Repetition and rehearsal § Mastery builds confidence
• Degrees of transparency § Individualize approach
• Set up for success § Graduate to more challenging, but pacing is crucial
• Fun and reinforcing § Maintain engagement and motivation
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Portable Prac0ce Kit • Must HAVES:
§ Fluency and familiarity with CDI and VDI skills § Creativity § Intentional plan with backup plan § Spontaneity (but NOT spontaneous practice)
• Optional: § Wipe board or paper § Reinforcement board § Familiar games or activities § Prizes
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Taking it on the Road…
• Flip cards with favorites • Brave Bingo • I Spy • Scavenger Hunt
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Daily Homework • Attend to the cycle: awareness is crucial first step • Monitor your use of questions or prompts to
verbalize • Practice CDI and CDI/VDI 5 minutes daily to gain
mastery and to acclimate § Needs to become fluid, like a second language
• Refer to the ‘talking map’ and establish the first target
• Select planned and intentional situations to begin using the skills daily to build brave muscles § 2-3x a day
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Helpful Resources
• www.childmind.org
• www.selectivemutism.org
• www.pcit.org
• www.selectivemutismlearning.org
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Next Workshop
Coexisting Disorders in Children With Selective Mutism: How to Differentiate Symptoms and Navigate Behaviors Wednesday, March 16, 2016 Time: 06:15 PM — 07:30 PM
Child Mind Institute 445 Park Avenue (with entrance on 56th Street) New York, NY 10022
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